Laserfiche WebLink
❑ ABANDONMENT/REMOVAL ❑ NEW CONSTRUCTION ❑ `SUBSURFACE ASSESSMENT/REMEDIATION <br /> ❑ ABANDONMENT/IN PLACE ❑ REPAIR OR REPLACE PRECISION TEST:OATE / J <br /> SITE INFORMAAT/ION: <br /> Site Address 4,az) L\ <br /> Facility Name �y1C"Cr� Y�V`Ir CitYCross StreetIZip <br /> Owner/Operator <br /> Mai I ing Address Phone <br /> City Zip <br /> CONTRACTOR INFORMATION: CONSULTANT INFORMATION: <br /> Company Company <br /> Address <br /> Address <br /> City Phone City Ph <br /> Contractor Lic. No./Class one <br /> Registration Lic. No/Type <br /> TANK CLEANING/TRANSPORTER INFORMATION: PRECISION TESTER INFORMATI <br /> Company <br /> Address <br /> Address <br /> Address <br /> City Phone city i ---'t' <br /> Waste Transporter ID No. Phone <br /> Tank Destination Type of Test r '1 <br /> Tester Name � - ' <br /> Rinsate Manifested (3 Tank Manifested E3 CA State Cert. No. <br /> TANK INFORMATION <br /> PREVIOUSLY <br /> PERMIT t SIZE PRODUCT AGE OF TANK STORED MATERIAL <br /> DESCRIBE WORK TO BE PERFORMED 1 <br /> i <br /> OFFICIAL USE ONLY (Use Reverse Side if Necessary) <br /> Site I.D. CT W) •t APN 4} <br /> Fee S App 1 i cat i on Date�,�Y� <br /> NOTE: Permit expires ninety (90) days after the application date. The applicant has received, <br /> understands, and will comply with the attached conditions of this permit and any other\ <br /> ��tete'end loco�rregulations.. <br />